First Shamrock Care Center
1415 South Main Street, Kingfisher, OK 73750 · For profit - Corporation · 55 certified beds · (405) 375-3157 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $29,726 in federal fines (most recent 2026-05-06)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 3.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 1.9% | 1.9% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.6% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 31.1% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 42.5% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.7% | 94.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.7% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 5.3% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 62.1% | 17.5% | 17.1% | check this† — see note marked dagger below the table |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 55 beds and averages 37.7 residents a day — about 69% occupied, or roughly 17 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.14 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 3.27 on weekdays — 1% thinner on weekends. RN hours go from 0.09 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-05-06 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement for 1 (#19) of 3 sampled residents reviewed for accidents. Resident #19 eloped through a facility window. The administrator identified 16 residents at risk for elopement. On 04/28/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement resulting in Resident #19 eloping.On 04/28/26 at 6:43 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 04/28/26 at 6:53 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 04/29/26 at 3:02 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Elopement policy and procedures reviewed and revised - signature 4.30.2026 at 12 PMResident #19 care plan was reviewed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2026-05-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse for 1 (#19) of 3 sampled residents reviewed for abuse. Resident #19 was physically abused by another resident. A review of an undated facility video monitoring showed Resident #20 attempted to grab a TV remote from the table where Resident #19 was. Resident #19 grabbed the remote and held onto it. Resident #20 continued attempts to take the remote from Resident #19 standing over them. Resident #19 asked Resident #20 several times not to touch it and to get away from them. Resident #19 was cussing at Resident #20 as they persisted at their approached. Resident #19 asked Resident #20 if they wanted their (curse word withheld) beat and stood up from their sitting position. Resident #20 responded, Yes, whip my [curse word withheld]. Resident #20 swung and hit Resident #19 on their face. CNA #4 stated from the dining area Hey stop it, both of you stop. CNA #4 was walking into the common area from the dining area with a cart. Resident #19 told Resident #20 to get away…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2026-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to:a. provide adequate supervision and a secure environment to prevent elopement for a resident with known exit seeking behaviors for 1 (#19). Resident #19 eloped through a facility window, andb. implement fall interventions for 1 (#3) of 3 sampled residents reviewed for accidents. An admission assessment for Resident #19, dated 07/28/25, showed the resident wandered and their cognition was severely impaired.A wandering and elopement risk assessment for Resident #19, dated 07/28/25, had four areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, history of wandering, confusion and disorientation, and dementia. A wandering and elopement risk assessment for Resident #19, dated 01/29/26, had two areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-05-06 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State Agency was available to the residents.The facility manager identified 37 residents resided in the facility. Findings:On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no information regarding filing a complaint with the State agency.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group was asked if they had been informed of their rights and given information on how to formally complain to the State about the care they were receiving. They stated, No.On 04/28/26 at 10:20 a.m., the administrator stated the information on how to formally file a complaint with the State Agency was not posted at this moment.
- Potential for harm · F2026-05-06 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based observation and interview, the facility failed to post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to the public.The facility manager identified 37 residents resided in the facility. Findings: On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no posted information on where the past State survey results were located. On 04/28/26 at 10:15 a.m., the administrator showed the location of the past State survey results. The binder was to the right of the facility entrance door.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group stated they did not know where to locate past State survey results.On 04/28/26 at 10:16 a.m., the administrator stated a sign was posted to show location of past State survey results, but it was taken down by a resident. They stated they were not sure when it was removed by the resident.
- Potential for harm · F2026-05-06 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents had access to the grievance procedure.The facility manager identified 37 residents resided in the facility. Findings:On 04/28/26 at 10:12 a.m., both resident halls, both nurses' stations, and the main living area were observed. There was no information regarding the facility's grievance procedure or location of grievance forms. The grievance personnel information was posted.On 05/06/26 at 1:37 p.m., the facility grievance binder was reviewed. There were no grievances.A Grievance Policy, dated 11/28/16, read in part, The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service; will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance.On 04/28/26 at 10:03 a.m., a confidential interview was held with the resident council group. The resident council group stated they did not know how to file a grievance.On 04/28/26 at 10:20 a.m., the administrator stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-05-06 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours seven days a week.The facility manager identified 37 residents resided in the facility. Findings: An RN coverage policy, reviewed 01/01/26, read in part, Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience.Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week.The facility must designate a registered nurse (RN) to serve as the DON on a full-time basis. A Punch Audit Report, dated 11/01/25 through 04/26/26, showed no RN hours for 10/01/25 through 10/03/25 10/06/25 through 10/15/25, 10/18/25 through 10/19/25, 10/21/25, 10/25/25 through 10/26/25, 10/28/25, 11/01/25 through 11/02/25, 11/06/25 through 11/09/25, 11/13/25, 11/27/25, 12/04/25, 12/08/25, 12/11/25, 12/22/25, 12/25/25, and 12/31/25. On 04/29/26 at 10:08 a.m., the business office manager stated between October 1st and October 14th, the facility had no RN coverage. They stated there was no RN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-05-06 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure an extended menu with portion sizes was available for use during one of one meal service observed.The facility manager identified 37 residents who received meal services from the kitchen. Findings:On 04/27/26 at 7:50 a.m., a facility extended menu was requested during entrance conference.On 05/05/26 at 8:23 a.m., [NAME] #1 was observed to put a 5-ounce scoop of scrambled eggs on two plates.On 05/05/26 at 8:27 a.m., [NAME] #1 was observed to put 4-ounce spoon of scrambled eggs on three plates.On 05/05/26 at 9:02 a.m., the administrator brought a box to the surveyors and was observed to shift through the paper items. There was no extended menu in the box.On 05/05/26 at 6:56 a.m., [NAME] #1 stated the breakfast menu was biscuit and gravy, hash brown, scrambled eggs, and cold cereal.On 05/05/26 at 8:28 a.m., [NAME] #1 stated the proper portion size should be 4-ounces of scrambled eggs.On 05/05/26 at 9:06 a.m., the administrator stated the facility did not have an extended menu at this time.On 05/05/26 at 10:07 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-06 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident was not administered a psychotropic medication without adequate indications for its use and received gradual dose reductions for 1 (#4) of 5 sampled residents reviewed for unnecessary medications.The RNC identified 28 residents were prescribed psychotropic medications. Findings: An undated EHR facesheet for Resident #4 showed the resident had diagnoses which included vascular dementia (severe) with psychotropic disturbances, depression, and an anxiety disorder due to known physiological condition. A facility policy titled Policy on Unnecessary Drugs, dated 01/01/99, read in part, All medications prescribed to residents must be based on an individual assessment of each resident's clinical condition, needs, and goals of care. Medications must be regularly reviewed to determine their continued necessity and appropriateness.A discontinued medication order, dated 02/17/25, showed Resident #4 had received an order for Invega Sustenna (an antipsychotic) 78 mg once a month for the first time for the diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-06 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to inform a resident or their representative of the risk, benefits, and alternative treatment options prior to giving psychotropic medications for 1 (#4) of 5 sampled residents whose clinical records were reviewed for unnecessary medications.The RNC identified 28 residents were prescribed psychotropic medications. Findings:The undated clinical record facesheet showed Resident #4 had diagnoses which included vascular dementia (severe) with psychotic disturbance, depression, and an anxiety disorder due to known physiological condition (history of).The facility's medication consent form binder from 2025 was reviewed. A consent form dated 05/05/25 for clozapine 75 mg four times a day for Resident #4 was found. There was no other documentation the resident or the resident's representative had been informed of the risks and benefits of the use of other psychotropic medications, treatment alternatives/options, and the choice of treatment the resident preferred before receiving the psychotropic medications. A physician's order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#4) of 12 sampled residents whose care plans were reviewed.The facility manager identified 37 residents resided in the facility. Findings: An undated policy titled Care Plans - Baseline, read in part, To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.A significant change assessment, dated 06/17/25, showed Resident #4 had diagnoses which included anxiety, vascular dementia (severe) with psychotropic disturbance, depression, acute and chronic respiratory failure with hypoxia, and an original admission date of 12/03/24, and a reentry date of 05/30/25.Review of the electronic health record did not show a baseline care plan was developed for Resident #4.On 05/05/26 at 1:24 p.m., the facility manager stated they could not find the baseline care plan for Resident #4, which meant there was not one for them.
- Potential for harm · D2026-05-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for a antidepressant and an antipsychotic for 1 (#37) of 5 sampled residents who were reviewed for unnecessary medications.The facility manager identified 37 residents resided in the facility. Findings:A Policy on Unnecessary Drugs, dated 01/01/1999, read in part, To ensure that residents in the long-term care facility are prescribed medications based on their clinical needs, avoiding unnecessary drugs that could lead to adverse effects, interactions, or diminished quality of life.Criteria for Identifying Unnecessary Drugs: Lack of a documented clinical indication for the medication.Documentation will include the rationale for continuing, discontinuing, or adjusting any medication, as well as discussions with the resident or their representative.A significant change assessment, dated 11/06/25, showed Resident #37 was severely impaired in cognition for decision making, had diagnoses of dementia and psychotic disorder, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-06 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure water was not utilized to puree foods for 1 of 1 breakfast meal observed.Cook #1 identified one resident on a pureed diet resided in the facility. Findings:On 05/05/26 at 7:54 a.m., [NAME] #1 was observed to place two hash brown patties in a blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the hash browns.On 05/05/26 at 8:06 a.m., [NAME] #1 was observed to add a 5-ounce scoop of scrambled eggs to the blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the scrambled eggs.On 05/05/26 at 8:12 a.m., [NAME] #1 was observed to place one and a half biscuit in a blender. [NAME] #1 was observed to add an unmeasured amount of hot water to the blender and puree the biscuits.On 05/05/26 at 7:56 a.m., [NAME] #1 stated they did not know how much water they added to the hash browns. They stated they just added water to food items until it was pureed.On 05/05/26 at 10:07 a.m., [NAME] #2 stated they used a half cup of hot water to puree food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2026-05-06 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. provide adequate supervision and a secure environment to ensure residents at risk for elopement had not eloped for 1 (#19) of 16 sampled residents at risk for elopement. Resident #19 was at risk for wandering and elopement. The care plan for Resident #19 did not show a concern for wandering and elopement risk prior to 03/21/26. Dietary Aide #2 stated they found Resident #19 in their truck. A combined initial and final state reportable form 283, incident date of 03/21/26, showed Resident #19 was observed seated in an employee's vehicle. The report showed the resident was an elopement risk. The report showed Resident #19 exited through a window of an empty room. MDS Coordinator #1 stated they were not aware the resident had exit seeking behaviors.b. protect resident's right to be free…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-06 · tag F0841 — isolatedDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the medical director verified the appropriateness of an antipsychotic medication for 1 (#4) of 5 sampled residents reviewed for unnecessary medications.The facility manager identified 37 residents resided in the facility. Findings:A review of an undated EHR facesheet for Resident #4 showed the resident had diagnoses which included vascular dementia (severe) with psychotropic disturbances, depression, and an anxiety disorder due to known physiological condition. A physician's order, dated 11/10/25, showed Resident #4 had an active order for Invega Sustenna (antipsychotic medication) 156 mg/mL once a day on the 10th of the month. Invega Sustenna is used primarily to manage schizophrenia and schizoaffective disorders. The record showed the medication was prescribed for the diagnosis of vascular dementia (severe) with psychotic disturbances. A quarterly assessment, dated 06/17/25, showed Resident #4 did not have potential indicators of psychosis which included hallucinations and delusions. The assessment showed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-21 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents were free from abuse for 2 (#1 and #5) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility.Findings:An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and mistreatment.1.A care plan for Res #1, dated 08/10/24, showed Resident #1 had a problem with agitation and aggressive behavior. Approaches included to separate from stressful situations, persons or places, understand triggers, observe for signs of frustration and intervene early.Res #1's annual assessment, dated 07/24/25, showed the resident's cognition was severely impaired. The assessment showed the resident had diagnoses which included non-Alzheimer's dementia, schizophrenia, depression, and anxiety. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to report allegations of abuse to the Oklahoma State Department of Health for 1 (#1) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility. Findings:An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy, read in part, Administrator or DON will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours. The administrator and/or designee will notify the Oklahoma State Department of Health within 24 hours, by fax or telephone, of an actual abuse. A report of the incident shall be mailed/faxed to OSDH within 5 working days of the incident.An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, major depressive disorder, anxiety disorder, dissociative and conversion disorder.An annual assessment, dated 07/24/25, showed Res #1's cognition was severely impaired. The assessment showed the resident had delusions; verbal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident-to-resident abuse for 1 (#1) of 6 sampled residents reviewed for abuse.The DON reported 44 residents resided in the facility.Findings: An undated facility policy titled Resident to Resident Abuse/Abuse Prohibition Policy, read in part, Administrator or DON will initiate an immediate investigation of alleged abuse at the time of occurrence, and document findings. Investigation will continue for a minimum of 72 hours.An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, major depressive disorder, anxiety disorder, dissociative and conversion disorder.An annual assessment, dated 07/24/25, showed the Res #1's cognition was severely impaired.A nurse note, dated 08/13/25 at 1:43 p.m., showed Res #1 was witnessed by staff running up behind Res #5, jumping up, and as Res #1 came back down, hit Res #5 near the neck/shoulder/head area. The residents were separated immediately and assessed. Res #5 denied any pain but had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention related to aggressive behaviors for 1 (#1) of 6 sampled residents reviewed for care plans.The DON reported 44 residents resided in the facility.Findings: An undated resident face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, expressive language disorder, restlessness and agitation.A care plan, initiated 08/10/24, showed Res #1 had agitation and aggressive behavior with no new interventions added to the care plan since 08/10/24.An annual assessment, dated 07/24/25, documented Res #1s cognition was severely impaired. The assessment showed the resident had delusions; verbal behavioral symptoms directed toward others daily which put the resident at significant risk for physical illness or injury. The assessment showed the behaviors significantly interfered with the resident's participation in activities and social interactions.A nurse note, dated 08/13/25 at 1:43 p.m., showed Res #1 was witnessed by staff running up behind Res…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure antipsychotic medications were administered as ordered for a serious mental illness for 1 (#1) of 6 sampled residents reviewed for behaviors.The DON reported 44 residents resided in the facility.Findings:An undated face sheet showed Res #1 had diagnoses which included disorganized schizophrenia, vascular dementia, major depressive disorder, and anxiety. A care plan, dated 08/10/24, showed Res #1 had a problem with psychotropic drug use, had an active diagnosis of schizophrenia and required anti psychotic medications. Interventions included the nurse would monitor and report side effects/behaviors to the physician.A physician order, dated 05/04/25, showed Uzedy (an antipsychotic) suspension 125mg/0.35ml; 1 injection subcutaneous once a day every 28 days for disorganized schizophrenia. A treatment administration record, dated 06/01/25 - 06/30/25, showed a missed injection on 06/01/25.An annual assessment, dated 07/24/25, documented Res #1s cognition was severely impaired. The assessment showed the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately complete a quarterly assessment for one (#3) of twelve sampled residents reviewed for accurate MDS assessments. The facility manager identified 40 residents resided in the facility. Findings: The facilities Accuracy of MDS Assessment policy, undated, read in part, the assessment must accurately reflect the resident's status. Resident #3 was admitted with diagnosis of mood disorder, bipolar, schizoaffective disorder, and major depression. A Medication Regimen Review dated 05/14/24, documented pharmacist recommending a GDR for medications Venlafaxine, Trintellix, and Lamotrigine. Recommendation denied by doctor with reason stating A reduction would likely worsen or destabilize resident's condition. A Medication Regimen Review dated 05/14/24, signed by doctor 05/24/24, documented physician response as disagree due to patient continues to cycle and have behaviors at times. A reduction would likely cause a decline. A Quarterly assessment, dated 05/23/24, documented in section N the last GDR was completed on 09/5/21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of two sampled residents for discharge summaries. The facility manager identified 40 residents resided in the facility. Findings: The facilities' Discharge Summary and Plan policy, revised 04/2009, read in part, When a residence discharge is anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Resident #40 was admitted on [DATE] with diagnoses which included depression, protein malnutrition , Wernicke's encephalopathy,chronic systolic, mixed hyperlipidemia, cerebral infarction, and nicotine dependence. There was no discharge summary located in the Residents clinical health record. A facility Against Medical Advice form, dated 05/9/24, documented Resident #40 signed the form and acknowledged the risk of discharging against medical advice. On 07/19/24 at 9:53 a.m., the facility manager was asked to provide a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure opened food items were labeled with the date opened and opened food items were stored in a sealed container. The facility manager identified 38 residents received nutrition from the kitchen. Findings: The facility's IT IS THE POLICY OF [Name Deleted] document, undated, read in part, All food coming into the kitchen will be labeled and dated upon entering. The document also read, All food once opened, will be labeled, dated, and stored in an airtight container, wrapped in plastic wrap, or placed in sealed bags prior to being refrigerated or frozen. 07/16/24 9:10 AM initial tour of kitchen The following items were observed in the refrigerator during initial tour of the kitchen: a. 1 bag of whipped topping opened, b. 1 bag salad mix opened with no date , c. 1 bag of shredded cheese opened with no date, d. sliced cheeses opened, not covered, and no date, e. Ranch and french dressing opened with no date, On 07/16/24 9:15 a.m., cook #1 was shown the above items from the refrigerator and asked what was the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reciew, and interview, the facility failed to ensure enhanced barrier precautions notifications were is place for two (#2 and #21) sampled residents reviewed for enhanced barrier precautions. The facility manager identified two residents with indwelling devices requiring enhanced barrier precautions. Findings: The facility's It is the Policy of First Shamrock policy, undated, read in part,Post clear signage on the door or wall outside of the residence room, indicating the types of precautions and required personal protective equipment. 1. Resident # 12 was admitted on [DATE] with diagnoses which included epilepsy and neuromuscular dysfunction of bladder. Resident #2's physician order, dated 06/20/24, documented a foley catheter in place and enteral feeding tube site care. On 07/16/24 at 11:22 a.m., Resident #2 was observed to have a enteral feeding tube and a catheter. No enhanced barrier precaution notification was observed posted. 2. Resident #21 was admitted on [DATE] with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-30 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a RN was designated to serve as DON on a full time basis. A Daily Census report, dated 01/29/24, documented 35 residents resided in the facility. Findings: A Director of Nursing policy, dated August 2006, read in part, .The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse .licensed by this state, and has experience in nursing service administration, rehabilitation, and geriatric nursing . An Employee Changes report, undated, didn't identify an employee as the DON. On 01/29/24 at 7:00 a.m., RN #1 was asked who was the DON. They stated they have a nurse manager. They identified the nurse manager as a LPN. On 01/29/24 at 7:31 a.m., CMA #1 stated the nurse manager was the DON. On 01/29/24 at 7:49 a.m., the nurse consultant was asked who was the DON. They hesitated then walked away without providing an answer.
- Potential for harm · E2024-01-30 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a system was in place to manage and safeguard residents' personal funds for two (#3 and #4) of three sampled residents whose trust accounts were reviewed. A Resident Trust Fund report, dated 01/29/24, documented 15 residents were in the trust account. Findings: A Trust Fund Policy, undated, read in part, .accounting principles means that facility staff employ proper bookkeeping techniques .Proper bookkeeping techniques include an individual record .for each resident on which only those transactions involving his or her personal funds are recorded and maintained. The record should have information on when transactions occurred, what they were, and maintain the ongoing balance for every resident . 1. A Resident Petty Cash Log, dated 08/24/23, documented Resident #3's balance was $455. A Resident Petty Cash Log, dated 08/30/23, documented Resident #3's carry over balance was $155. There was $300 unaccounted for. 2. A Resident Petty Cash Log, dated 10/31/23, documented Resident #4's balance was $63. A Resident Petty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-30 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a system was in place to manage and safeguard residents' personal funds to prevent misappropriation of residents' funds for two (#3 and #4) of three sampled residents who's trust accounts were reviewed. A Resident Trust Fund report, dated 01/29/24, documented 15 residents were in the trust account. Findings: A Trust Fund Policy, undated, read in part, .accounting principles means that facility staff employ proper bookkeeping techniques .Proper bookkeeping techniques include an individual record .for each resident on which only those transactions involving his or her personal funds are recorded and maintained. The record should have information on when transactions occurred, what they were, and maintain the ongoing balance for every resident . 1. A Resident Petty Cash Log, dated 08/24/23, documented Resident #3's balance was $455. A Resident Petty Cash Log, dated 08/30/23, documented Resident #3's carry over balance was $155. There was $300 unaccounted for. 2. A Resident Petty Cash Log, dated 10/31/23, documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-27 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an Advance Directive for two (#23 and #26) of 16 sampled residents reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility. Findings: An Advance Directives policy, revised 04/08, read in parts, .Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care .the right to formulate advance directives .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives . 1. Resident #23 had a current admission date of 07/05/22. On 06/20/23 at 12:45 p.m., the RN consultant and Facility Manager were asked for Resident #23's Advance Directive or acknowledgement form for an Advanced Directive. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-27 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete pre-employment screening for history of abuse and neglect per their abuse policy for two (CNA #1 and RN #1) of five employee files reviewed. The current Employee List, undated, documented 39 facility employees. Findings: A Resident to Resident Abuse/ Abuse Prohibition policy, undated, read in part, .Screening: All potential employees will be screened for a history of abuse, neglect or mistreating resident. This facility will obtain OSBI checks, attempt to obtain information from prior employers, current employers and licensing boards and registries . CNA #1 had a hire date of 02/05/18. The OK Screen for CNA #1 was dated 02/07/18. RN #1 had a hire date of 11/01/22. The OK Screen for RN #1 was dated 11/17/22. On 06/22/23 at 3:55 p.m., the Facility Manager was asked to clarify the hire dates and the OK Screen dates of the above staff members. They stated they had spoken to a representative from the State agency and they were allowed 10 days from the hire date to get the OK Screen results back. They were asked to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-27 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure: A. an RN worked eight consecutive hours seven days a week, and B. an RN was designated to serve as DON on a full time basis. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility. Findings: On 06/20/23 at 9:13 a.m., during the Entrance Conference Meeting, the LPN Facility Manager and RN Consultant were asked who the full time DON was for the facility. The LPN Facility Manager stated they had an RN waiver in the past. They stated they had applied for a renewal and the State office had informed them they did not have to have an RN who was acting as the DON. They stated they had RNs on staff, but no one who would take the DON position. The LPN Facility Manager was asked if they had an RN that worked eight hours a day. They stated, No. The fiscal year quarter two PBJ Staffing Data report, dated 06/19/23, documented the facility had no RN hours on 02/16/23, 02/23/23, 02/28/23, 03/08/23, 03/09/23, 03/10/23, 03/14/23, 03/21/23, 03/22/23, 03/23/23, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-27 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one ( #43) of 16 sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility. Findings: A Care Plans - Preliminary policy, revised August 2006, read in parts, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission .To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission .The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan . Resident #47 was admitted on [DATE] with diagnoses which included Parkinson's disease, other seizures, and generalized anxiety disorder. No baseline…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to fully develop a comprehensive care plan for one (#26) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents with behavioral healthcare needs and 35 residents on psychoactive medication. Findings: A Care Plans- Comprehensive policy, revised 10/10, read in parts, .An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Resident #26 had diagnoses which included psychotic disorder with hallucinations due to known physiological condition, Alzheimer's disease, depression and insomnia. Physician Orders, dated 01/03/23, documented the resident was to receive Lamictal, Lexapro, and Rozerem. A Significant Change Resident Assessment, dated 02/24/23, documented the resident was observed for the behavior of hallucinations, experienced the behavior of wandering, and received an antidepressant,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure hospitality aides did not provide feeding assistance to residents for two (#24 and #26) of two sampled residents observed being assisted during the lunch meal service. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 39 residents required the assistance of one or two staff members for eating and one resident was dependent on staff for the task of eating. Findings: 1. Resident #24 had diagnoses which included Huntington's disease and depression. A Physician Order, dated 02/09/22, documented the resident was to receive nectar thick liquids. A Physician Order, dated 03/09/22, documented the resident was to receive a mechanically altered diet, puree consistency. A Quarterly Resident Assessment, dated 05/16/23, documented the resident required limited assistance of one person physical assist for the task of eating. A Care Plan, revised 05/17/23, documented Resident #24 ate in the dining room and staff would encourage, cue, and remind the resident for all meals. 2. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain lab as ordered per physician order for one (#21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 06/20/23, documented 40 residents resided in the facility. Findings: Resident #21 admitted with diagnoses which included cerebral infarct, seizures, and resistance to antimicrobial drugs. A Physician Order, dated 01/31/23, documented Vitamin D 5000 units by mouth daily. A Medication Regimen Review, dated 03/08/23, documented a request to add yearly vitamin D level. The attending physician responded to the pharmacy recommendation by circling agree and signed and dated the form 03/27/23. There was no vitamin D level lab results located in the residents clinical record. On 06/23/23 at 11:13 a.m., the LPN Facility Manager was asked who was responsible for responding to pharmacy recommendations. They stated, the physician responded to them and the LPN Facility Manager received them. They were asked to review the recommendation from 03/08/23 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$29,726 in federal fines across 1 penalty.
- $29,726 — penalty dated 2026-05-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to BGM ESTATE — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.8 | -0.8 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 1 of 5 | 2.5 | -1.5 vs chain |
The other 14 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ANGELUS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 13% | since 12/12/2025 |
| BGM ESTATE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 38% | since 08/01/2019 |
| PHILIP M. GREEN REVOCABLE TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 08/01/2019 |
| PHILIP MARION GREEN EXEMPT TR CU GILBERT F GREEN TR | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 11% | since 12/12/2025 |
| TIFFANY SEAY EXEMPT TR | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 14% | since 12/12/2025 |
| MITCHELL, KELLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 08/01/2019 |
| MITCHELL, MARCINDA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 08/01/2019 |
| MITCHELL, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 08/01/2019 |
| TABOR, ANGELA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 08/01/2019 |
| BELT, MIRANDA | Individual | CORPORATE OFFICER | — | since 12/09/2024 |
| PITTS, JACI | Individual | CORPORATE OFFICER | — | since 12/09/2024 |
| TAYLOR, SANDRA | Individual | CORPORATE OFFICER | — | since 08/01/2019 |
| CABLE, RONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2022 |
| JORDAN, KRISTEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/28/2021 |
| LIPSKA, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/18/2025 |
| MUNOZ, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/03/2019 |
| SNYDER, RHIANNON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/02/2024 |
| SUTTON, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/08/2015 |
| THROWER, CHASE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/15/2025 |
| WAHWEAH, PEGGY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/14/2025 |
| GREEN, PHILIP | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/29/2026 |
| ADVANCED WOUND THERAPY | Organization | ADP OF THE SNF | — | since 11/01/2024 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 01/01/2010 |
| MOBILE WOUND CARE LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| NS GROUP CONSULTING DIVISION | Organization | ADP OF THE SNF | — | since 11/01/2024 |
| PHARMCAREOK OF DURANT INC | Organization | ADP OF THE SNF | — | since 11/01/2015 |
| STEIN ANCILLARY SERVICES, LLC | Organization | ADP OF THE SNF | — | since 09/01/2014 |
CMS files one row per role, so the 38 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.
11 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 95% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $272K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375416. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.